Regents Optional Retirement Plan
Election
TR-53 (0921)
To Be Completed by Employee -- please print clearly
_________________________________
Date of Birth
_________________________________ __________________________ ___________________
Last Name First Name Middle Initial
___________________________________________________________________________________
Address
______________________________________________ ____________ ______________________
City State Zip Code
List all previous employment with the University System of Georgia on page 2.
I understand that this selection is irrevocable during the tenure of my employment in a covered position with
the University System of Georgia.
_________________________________________________ ______________________________
Employee’s Signature Date
To Be Completed by Employer -- please print clearly
I hereby certify that the above employee is eligible to join the Regents Optional Retirement Plan (ORP).
This employee was newly hired in an eligible position on ______________________________________
Employment Date
and, if applicable, has terminated all previous employment with the University System of Georgia.
___________________________________________________________________________________
Reporting Employer’s Name
_________________________________________________ ______________________________
Approving Authority’s Signature Date
_________________________________________________ _____________________________
Authority’s Printed Name Title
Social Security Number
*ME-2*
Teachers
Retirement
System of
Georgia
Two Northside 75 Suite 100 Atlanta, GA 30318 (404) 352-6500 (800) 352-0650 fax (404) 352-4885 www.trsga.com
Page 1 of 2
As provided for by the Regents Optional Retirement Plan legislation, I hereby give notice to the Teachers Retirement
System of Georgia (TRS) Board of Trustees of my selection of the optional retirement plan. Eligible employees of
the University System of Georgia have 60 days from the date of employment to elect TRS or ORP membership.
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
